Update on Ocular Dermatology COPE 51248-AS [Read-Only] on Ocular... · 2016. 11. 29. · eyelids,...
Transcript of Update on Ocular Dermatology COPE 51248-AS [Read-Only] on Ocular... · 2016. 11. 29. · eyelids,...
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Update on Ocular Dermatology
Dawn Pewitt, OD, FAAOTriad Eye Institute, Grove, OK
COPE 51248-AS
• No Financial Disclosures
Benign Eyelid Lesions
• Epithelial & adnexal tumors• Vascular tumors• Xanthomatous tumors• Infectious
Epithelial & Adnexal Tumors
• Squamous papilloma• Seborrheic keratosis (SK)• Cutaneous cysts• Sweat gland (eccrine & apocrine)• Fibrous tissue
Squamous Papilloma
• Aka skin tags, achrochordons; fibroepithelial polyps
• Common around eyelids, neck, or near flexures
• Assoc with obesity and insulin resistance
Periorbital Papillomas
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Seborrheic Keratosis
• Abnormality of epidermal basal cell maturation that results in a well-defined, raised, rough-surfaced papule or plaque.
• Classic waxy or “stuck-on” appearance.
• Usually asymptomatic but may itch or become inflamed.
Seborrheic Keratosis
• Is the most common differential diagnosis of a malignant melanoma.
• Patient reassurance.• Surgery vs.
cryotherapy.
Seborrheic Keratosis Cutaneous Cysts
• A cyst is a closed cavity or sac containing fluid or semi-solid material within an epithelial, endothelial or membranous lining. • Epidermoid cyst: a cutaneous or subQ cystic
swelling of the skin, often with a central punctum, derived from squamous epithelium
• Dermoid cyst: a developmental cyst resulting from inclusion of embryonic epithelium at sites of embryonic fusion
• Milia (whiteheads): small epidermoid cysts that presents as a white or cream-colored papule
Epidermoid Cyst• Most occur
spontaneously, can be assoc with acne.
• Multiple cysts occur in Gardner’s syndrome.
• Usually asymptomatic but can be inflamed.
Epidermoid Cyst
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Epidermoid Cyst Dermoid Cyst• Often present at birth.• Occur most commonly on the face, midline of the neck
and the mastoid area.
Milia (Whiteheads)• Common in acnes. • Asymptomatic. • Usually occur on face but
can develop anywhere when related to a blistering process.
• Often disappear spontaneously in you after a number of months. • Formerly I&C • Laser ablation
Sweat Gland Tumors
• Eccrine hidrocystoma: rare disorder of the eccrine sweat duct that results in several small swellings, usu adjacent to the eyelids. It occurs particularly in hot climates.
• Syringomata: a benign tumor of sweat ducts; usually occurs as multiple lesions
Eccrine Hidrocystoma
• Multiple small swellings that increase in size with heat & become almost imperceptible in the winter.
• Occur mainly around the eyes.
• Most common in females.
• Air-conditioning helpful.
Syringomata
• Common in Asians & Afro-Caribbeans; can be familial; occur in Down syndrome.
• Occur symmetrically, particularly around the eyes in females.
• Reassurance vs gentle cautery.
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Apocrine Gland Tumors• A benign cystic tumor
of the apocrine secretory glands (gland of Moll).
• Slow growing, appears in middle age.
• Solitary dome-shaped. • No seasonal variation.
Fibrous Tissue Tumors
• Hyperproliferative responses of connective tissue to trauma resulting from an imbalance between collagen synthesis and lysis.
• Hypertrophic scars: confined to the area of trauma.
• Keloids: spread beyond the area of trauma -has a worse prognosis.
Keloid vs Hypertrophic Scar Vascular Tumor
• Pyogenic Granuloma: common benign vascular papule occurring in youth, possibly as a response to injury.
• Sudden onset & tend to bleed.
Xanthomatous Lesions
• Accumulations of xanthoma cells – macrophages containing droplets of lipids
• May be a symptom of a general metabolic disease or a local cell dysfunction
• Classification:1. Due to hyperlipidemia2. Normolipidemia
Xanthelasma
• Most common of all xanthomas
• Age of onset: over age 50
• Labs: fasting cholesterol and triglycerides
• 50% of patients have no metabolic disease
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Xanthoma
Striatum Palmare Eruptive Xanthoma
Infectious Lesions
• Impetigo• Verruca • Molluscum contagiosum
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Impetigo
• Common in the young
• Outbreaks occur in institutions (nurseries)
• Predisposing factor• Insect bite• Trauma• Eczema
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Impetigo
• Blisters remain for few days (yellow pus visible)
• Blister ruptures & golden crust forms
• Spreads rapidly• Ulceration if
infection is deeper
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Impetigo
• Topical antibiotics • Systemic antibiotics
for 5 days; they are effective within 24 hours
Verruca
Verruca plana (flat) Verruca vulgaris
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Filiform Wart• Small base with elongated shape• May have associated conjunctivitis
Molluscum Contagiosum
• Epidermal viral infection
• Common in children and immuno-compromised
• Histopathology• Basophilic
molluscum bodies
Molluscum Contagiosum• May be associated with chronic follicular
conjunctivitis
Molluscum Contagiosum• Management: excision, curettage,
cryotherapy, trichloroacetic acid
Solar Damage and Skin Cancer
• The propensity for solar damage depends upon:• Skin type• The cumulative exposure
to UV light• The intensity of exposure• The exposure in
childhood• Residence nearer to the
equator
Fitzpatrick Skin Types1) Always burns, never
tans **2) Always burns,
sometimes tans **3) Sometimes burns,
always tans4) Never burns, always
tans5) Black skin
Non-Melanoma Skin Cancer
• Cutaneous Horn• Actinic (Solar) Keratosis• Keratoacanthoma • Squamous Cell Carcinoma• Basal Cell Carcinoma
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Cutaneous Horn
• Marked keratin cohesion that gives rise to a horny outgrowth.
• May be caused by a wart, solar keratosis, keratoacanthoma or squamous cell carcinoma.
• Surgical excision with histologic eval.
Cutaneous Horn
• A red indurated base suggests SCC.
• A flat or sl raised base suggests AK.
• A well-defined warty base suggests seborrheic keratosis.
Keratoacanthoma
• Well-defined uniform nodule, either red or flesh colored.
• Central keratin-filled crater.
• Usually 1.5-2.0cm in diameter (or more)
• Involutes & leaves scar (~4 months)
Keratoacanthoma
Keratoacanthoma
Atlas of Clinical Dermatology, du Vivier. Figures 10.49, 10.50
Actinic Keratosis
• A premalignant disorder of the epidermis vs variant of squamous cell carcinoma.
• Often multiple lesions on chronically solar-exposed skin (face, ears, back of hands)
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Actinic Keratosis
• Management• Cryotherapy• Surgery• Topical therapy (5-
fluorouracil) • Photodynamic
therapy • Solar protection &
sunscreens
Actinic Keratosis
Squamous Cell Carcinoma
• A malignant tumor arising from keratinocytes that may metastasize.
• Twice as common in males. • UV irradiation most common cause.
Squamous Cell Carcinoma
• SCC starts as a thickening of the skin & becomes an indurated plaque.
• Grows laterally & vertically, becomes fixed & nodular
• Surface may be crusted, eroded or ulcerated.
Squamous Cell Carcinoma
• Most occur on sun-exposed areas. The surrounding skin usu has signs of actinic damage.
• Ear & lip lesions often metastasize
Squamous Cell Carcinoma
• Perineural infiltration of SCC of the eyelids facilitates spread into the orbit, intracranial cavity and periorbital structures via:• Trigeminal nerve
branches• Extraocular motor nerves• Facial nerve
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Conjunctival SCC Lymph Nodes of Eyelids
MOHS Basal Cell Carcinoma
• A common, locally destructive, malignant cutaneous tumor derived from the basal cells of the lower epidermis.
• Subtypes include: rodent, pigmented, cystic, superficial spreading
Basal Cell Carcinoma
• Occurs most commonly on face.
• Tend to bleed, scab, painless.
• Rarely metastasize but is locally invasive. • *Danger Zones (eye,
ear & nose)
Nodular BCC
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Basal Cell Carcinoma / Traction Rodent Ulcer BCC
Pigmented BCC
• Features similar to a rodent ulcer but the margins are heavily pigmented.
• May be mistaken for a Malignant Melanoma.
Superficial BCC
• Solitary patch on the trunk or limbs; often mistaken for psoriasis or eczema.
• Well-defined slightly raised, red plaque with adherent scale.
• Pearly borders.
Cicatricial BCC
• Most often misdiagnosed as a scar.
• Telangiectasia and pearly color.
• Spreads insidiously and is larger than appears.
H-ABCDS
• H = Hair / History• A = Asymmetry /
Avascular• B = Borders /
Bleeding
• C = Color / Changes • D = Diameter /
Distribution • S = Surface /
Symptoms
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Malignant Melanoma
• May arise spontaneously or from pre-existing lesions.
• Metastasis likely.
Lentigo Maligna
• Flat, pigmented lesion on the face that gradually enlarges.
• Aka Hutchinson’s freckle.
• Variable colors & irreglar margin.
Lentigo Maligna Melanoma
• LM is a precursor of LMM• 30% to 50% of LM
progress to LMM• Focal papular &
nodular areas signal invasion into the dermis.
Lentigo Maligna Melanoma
Superficial Spreading Malignant Melanoma
• Flat patch of pigmentation that becomes palpable. Spreads laterally & horizontally and has an irregular border.
Superficial Spreading Malignant Melanoma
• Tumors > 3mm thick have a poor prognosis.• Nonlinear relationship between depth of
invasion and survival rate.
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Nodular Malignant Melanoma
• Has no horizontal growth phase.
• Grows vertically ab initio.
MM - depth of lesion
• Lesions <0.75mm in thickness have ~90% survival rate at 10 yrs
• Lesions <0.75mm in thickness have ~100% survival rate at 5 yrs
• Lesions >1.5mm in thickness have ~50% to 60% survival rate at 5 yrs
MM Testing
• Blood work: liver panel (LDH, GGT, SGOT, SGPT, alkaline phosphatase)
• Chest x-ray
Recommend
• Color Atlas of Clinical Dermatology, 4th edition. Fitzpatrick et al.